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Patients’ Plastic Pieces Common Technology in Children with Medical Complexity

PHM 2016

Wendy Arafiles, MD

Sarjita Shukla, MD

Samuel Flores, MD

Kiran Mangat, MD

Disclosures • We have no financial relationships or commercial interests to

disclose

• We have received no financial incentives from any corporations involved in the manufacture or development of products employed in this presentation

• Any mention of brand names is used purely for efficiency of presentation

• All images utilized in this presentation were downloaded from the internet or included with permission.

Learning Objectives 1. Manipulate and learn the basics of common medical technology

including: Ventricular shunts Tracheostomies Chest tubes Long term central venous access Enteral tubes

2. Learn to troubleshoot common problems and concerns related to the above technology

3. Explore ways to lead discussions with families about the above procedures and subsequent care, including the more philosophical challenges of caring for a technology-dependent children

Introduction • Nationwide, children with medical complexity account for 0.5% of the population,

yet 25% of healthcare costs. • Hospitalists are involved in critically important episodes during these patients’

lives, and we are often asked to assist in decisions involving the placement and subsequent care of medical technology.

• We are expected to be familiar with our patients’ medical technology, empathize with the day-to-day challenges these patients and their families face, and troubleshoot and advise on problems that inevitably arise.

• This workshop is designed to suit the more advanced understanding of the target

PHM audience, and it will include thought- and discussion-provoking topics relevant to the care of medically complex and technology dependent children across the continuum.

Workshop Design • Large group discussion: Intro • Concurrent small groups:

A: Ventricular shunts B: Enteral tubes C: Tracheostomies and chest tubes D: Long-term central venous access – Explore physical items and electronic visual aids – Discuss aspects of care pertinent to each piece of technology including: patient/family education regarding

the surgical procedure, as well as expectations of care and troubleshooting problems in the immediate post-operative, subacute, and long-term periods.

• Reconvene large group: – Closing discussion of the more philosophical topics surrounding this patient population, touching briefly on

advance directives and goals of care discussions.

Ventricular Shunts

By

Sam Flores, MD

Most common shunt placement

CODMAN CERTAS® Plus Programmable Valve Components

Outlet

SIPHONGUARD®

Anti-Siphon Device

(Optional)

Valve Construct

Direction of flow

indicator

Reservoir

Suture Holes (4x)

Inlet

Right Hand Side

(RHS) Marker

New ruby bushing

DSUS/COD/1214/0233(1) 02/15

Medtronic Strata® II Valve View on X-ray

DSUS/COD/1214/0233(1) 02/15

CODMAN CERTAS® Plus Valve View on X-Ray

Medtronic Strata® Valve Reprogrammer

DSUS/COD/1214/0233(1) 02/15

CODMAN CERTAS® Tool Kit

Low Profile Locator Tool

Adjustable Height Locator Tool

Indicator Tool Adjustment Tool

X-Ray Overlay Tool

Adjustment with CODMAN CERTAS® Toolkit

• Things to learn with adjustment…. o Alignment is critical

o Height is critical- need to use

the Adjustable Height

Locator Tool appropriately

o Horizontal use (like a

compass)

o The indicator tool: if you drop

it, request a replacement.

DSUS/COD/0915/0412

DSUS/COD/1214/0233(1) 02/15

CODMAN CERTAS® Tool Kit Indicator Tool

• The position of the number in the window helps confirm that the tools are properly

aligned with the valve

Important Questions/Resident Teaching Points

• When shunt placed?

• Type of shunt (e.g. VP vs VA) and is it programmable?

• Do you have a pocket or wallet card that goes with your device?

• What was the most recent shunt setting?

• Date of last revision and reason for revision?

• Any history of infections?

Common Scenario • 3 yr old male with Codman programmable VPS

shunt placed in 2013 for hydrocephalus (status post revision 6 months ago) presents with a 1 day history of headache and vomiting. – X-ray Shunt series: intact shunt tubing – 1-bang MRI brain (or CT hydro): no increased

intracranial pressure, ventricle size stable – Neurosurgery consult: Admit and observe overnight

For the Hospitalist – Check valve type and setting on Xray and ask NSGY if it

needs to be re-programmed • Could (should) hospitalists have access to these tools to reprogram

shunts themselves?

– When is it necessary to “tap the shunt”? – Observe for Increased ICP

• Cushing Triad: Hypertension, bradycardia, and abnormal breathing

– What to do next if patient decompensates? • Transfer to ICU • Hyperventilate • Consider Hypertonic saline vs mannitol

Resources

• Hydrocephalus Association http://www.hydroassoc.org/docs/FactSheets/FactsheetShuntSystems.pdf

• Codman Neuro: http://www.depuysynthes.com/hcp/codman-neuro

• Medtronic: http://www.medtronic.com/us-en/healthcare-professionals/products/neurological/shunts.html

Tracheostomy Tubes Chest Tubes

by

Wendy Arafiles, MD

Tracheostomy Tubes

Anatomy of a Trach

Trachs: Cuffed and Uncuffed

Obturator: facilitates trach replacement (like a stylet)

Cuff: facilitates airleak management

Pilot balloon: indicates cuff inflation, can palpate cuff tension

Trachs: Shiley

Cuffed and Uncuffed, Neonatal and Pediatric sizes, firmer plastic material

Trachs: Bivona® Silicone material = more flexible

Uncuffed Cuffed

Flextend

Bivona® Flextend Tight-to-Shaft (TTS) • Extended length proximal shaft is flexible and allows for more neck

soft tissue, providing more distance between the patient and connected devices (e.g. ventilator)

• Wire embedded in tube maintains tube integrity despite the extended length and is non-ferrous (less distortion on XR imaging and MR-conditional)

• Deflated cuff rests “Tight-to-Shaft”

Trachs: Other

Fenestrated: Allows air to escape through vocal cords = vocalization

Metal

Inner cannula: • Outer cannula

stays in place up to 30 days, inner cannula removed and cleaned daily.

• Fenestrated and non-fenestrated

Trachs: Accessories PMV: Passy-Muir® Valve

• Allows inspiration but blocks expiration = forces air up through vocal cords

• aka “speaking valve”

Cap: Blocks all air passage (for weaning)

Ties: • Foam with velcro • Metal chain

HME: Heat Moisture Exchanger • Single or Double barrel • aka “nose”

Trach Placement • Placed in OR with ENT or general surgeon • New trach anchored in place by sutures • 5-7 day postoperative stay in ICU – allow new trach stoma to heal

before 1st trach change • 1st trach change performed by surgeon due to risk of false-tracking

upon replacement and need for advanced airway support during procedure

• Ideally, after ICU stay, patient will be cared for on a specialized airway unit for trach-specific caregiver education and discharge planning

Life after the Trach

• Notify local power company if patient has a ventilator

• Notify local Fire Station/EMS of patient with a trach (+/- ventilator)

• Leaving the house becomes much more complicated! – Trip reduction

• Access to emergency services

• Access to home health nursing and DME services

Chest Tubes

Chest tubes: Pigtail catheter • Placed in IR under fluoroscopy (or ED, ICU) • Smaller caliber than surgical chest tubes

therefore less painful • BUT easily becomes clogged with purulent or

fibrinous material • TPA is safe and oftentimes effective (but not

always) • 3-way stopcock facilitates delivery of TPA doses

(up to 3 doses, 24 hours apart) • Removal at bedside – remember to release the

locking mechanism that keeps the proximal end curled

Chest tubes: Drainage system

Chest tubes: Atrium drainage system

Atrium drainage system

A: Suction regulator

E: Suction bellows

C: Air leak monitor – oscillating ball and bubble window

B: Water seal chamber

D: Fluid collection chambers

Home chest tube drainage systems Passive drains • To drain intrapleural

fluid at home • Limited volume

capacity

Active drains • To drain intrapleural fluid at home • Larger volume capacity • Atrium product requires suction

source

Home chest tube drainage systems Heimlich or “Flutter” Valve • One-way valve to let

intrapleural air escape the thorax

• E.g. persistent air leak in bronchopleural fistula

• Meant for very stable patients with ~90% re-expansion to use at home

Indwelling Central Venous Catheters

By

Kiran Mangat, MD

Central Venous Catheters PICC Broviac®/Hickman® Port-a-Cath®/MediPort®

External Catheter Tunneled Not externally visible

Can be tunneled Externally visible Flush monthly

Power option for contrast Cuffed to grow into skin Externally accessed

Requires frequent flushing Open ended Intermittent use

Easily displaced Daily, long term use Less mechanical damage

Can be used up 6 months Durable, withstands punctures best of 3

Highest risk of infection

CVCs: Complications Immediate Delayed

Bleeding Infection

Arterial Puncture Thrombosis

Arrhythmia Catheter migration

Air embolism Catheter embolization

Thoracic duct injury Myocardial perforation

Catheter malposition Nerve injury

Pneumothorax

The smaller diameter catheter & fewer lumens should be used to reduce the risk of thrombosis.

CVCs: PICC • Often placed in IR, +/- sedation

• Can be performed at bedside with sterile field, +/- anxiolysis with midazolam

• Tip placement confirmed with bedside ultrasound, by measurement and post-placement CXR, or direct image guidance

• Upper extremity PICC: usually inserted into the cephalic, basilic, or brachial vein, advanced to cavoatrial junction

• Lower extremity PICC: usually inserted into the greater saphenous vein, advanced to the IVC

Tunneled CVC: • Placed in IR under GA with

fluoroscopy guidance • Inserted peripherally,

tunneled subcutaneously to vessel access point

• Usually used in patients with more difficult central access

CVCs: PICC Groshong® catheters: • Use of a heparin lock is not

necessary • No clamps on the external

length • Flush with NS weekly • Less risk of air embolus • Black tip with three-way valve

formed by slit in the sidewall of the catheter tip. ⁻ Valve opens outward during

infusion ⁻ Inward during blood

aspiration ⁻ Closed when not accessed

PowerPICC®: • Single-, Double-, or

Triple-lumen • Used for “power flush”

of IV contrast for imaging

CVCs: Broviac® & Hickman®

• Placed in the OR under GA

• Proximal catheter inserted directly into a central vein

• Distal catheter is tunneled under the skin and brought out on the chest or thigh away from the site where it enters the vein

• Tunneling prevents bacteria from gaining access to the central portion of the catheter

• Single- or Double-lumen available

Contain a "cuff" of Dacron material which is buried under the skin ⁻ Within a month, subQ fat tissue

grows into this "cuff" ⁻ stabilizes the catheter in the skin ⁻ acts as a barrier to infection *This is essentially what differentiates a Broviac from a tunneled PICC*

CVCs: Port-a-Cath® or MediPort®

• Placed in the OR under GA • Embedded under the skin and catheter is tunneled

subcutaneously then inserted into a central vein • Port is the size of a nickel or quarter, circular (or oblong or

triangle) in shape, palpable under the skin • Port has a raised septum of self-sealing rubber material in the

center through which the access needle is inserted • Meant for long-term intermittent access (septum has a limited

lifespan = # of “pokes”) • Less risk of complication when not accessed compared to

Broviac® • Requires heparin flush every month

Radiopaque Discrete

CVCs: Dressings

Accessed Portacath®

Broviac® dressing

CVCs: Dressings Biopatch®

Biopatch® Chlorhexidine impregnated sponge with 360 degree contact around the catheter at skin insertion site

StatLock®

StatLock® Locking device that adheres to skin and holds distal portion of the catheter in place to minimize movement at skin entry point

Tegaderm, Sorbaview®

Clear adhesive layer that covers entire apparatus optimizing visibility at insertion site

Removing a PICC 1. CLEAN PROCEDURE = wear mask, gown, gloves; tie hair back

2. Note the length of indwelling catheter from insertion records

3. Using non-sterile gloves: place a glob of vaseline on middle 1/3 of one edge of a 4x4 gauze – set aside; loosen all peripheral tape and dressings beforehand, but keep Tegaderm and Biopatch® securely in place directly over skin insertion site

4. Using a sterile glove, keep a finger over the catheter at insertion site and remove Biopatch® and remainder of dressing (prevent catheter from receding further into vessel)

5. Use Chloraprep® stick to brush off sand (if present) and clean insertion site, immediate surrounding area, and adjacent catheter

6. Place gauze with vaseline directly under catheter where it enters the skin, loosely fold two sides over the catheter

7. Holding slight pressure over the vaseline/gauze over catheter, slowly and steadily slide the catheter out through the vaseline/gauze

8. Once entire catheter is removed, keep holding the gauze over the insertion site and inspect the tip and length of catheter removed – ensure catheter is intact

9. Once inspection is complete, without removing vaseline gauze from insertion site, fold distal portion of gauze up to create a small pressure dressing – cover securely with Telfa dressing

CVCs: General troubleshooting

• Fibrin sheaths or thrombosis can develop

• Difficulty with draw but not flush = fibrin sheath

• Difficulty with both draw and flush = thrombosis

• Do not flush through it as the pressure can cause a break in lumen leading to a leak

• Usually try Alteplase for 30 minutes in catheter. If not improved, then try 2 hours. May require second dose.

• Alteplase will not work if crystallization has occurred due to incompatibility of infusions.

Tunneled CVCs: Pinch off syndrome

• Tunneled catheter passing through tissue of the space outside the vessel lumen becomes compressed between the clavicle and rib.

• Intermittent pain and occlusion.

• Occurs with subclavian vessel placement

• As the patient raises and lowers the shoulder, repeated compression and shearing forces put pressure on the catheter.

• Repositioning helps but if recurs, line needs to be replaced.

PICC and Tunneled CVC: Troubleshooting PICC

• Risk of phlebitis:

– Chemical

– Mechanical: due to presence of foreign body or wire irritation on lumen.

• Kinked dressing can occlude line

• Trial warm pack and range of motion q 2 hours to help

• If not flushing, change end cap or dressing.

Broviac®

• Families should keep plastic clamps handy.

• For any break, leak, or hole, clamp should be applied above damaged area and close to patient to prevent bleeding or air emboli.

Port

• Check position with X-ray, PA and Lateral

• Sometimes needle is not accessing due to short length

• If there is a leak, skin may develop swelling.

• Redness or blistering can occur if infusion is a vesicant.

• During a prolonged infusion, check needle position as it can be displaced.

Enteral Tubes

By

Sarjita Shukla, MD

Nasogastric (NG) & Nasojejunal (NJ) Tubes

Nasogastric (NG) & Nasojejunal (NJ) Tubes

NG/NJ Tube: Placement NGT

• Determine length (distance nose to ear lobe, then to xiphoid process)

• Confirm placement with AP CXR with upper abdomen

• ND can also be placed at bedside.

NJT

• Requires fluoroscopy to place tube tip distal to ligament of Treitz

NGT/NJT: Complications *Especially with long-term use*

• GER/Aspiration +/- pneumonia • Pharyngitis, Esophagitis, Otitis Media, Sinusitis • Bleed, Perforations, Mucosal tears • Nasal ulceration or pressure necrosis • Dislodgement • Obstruction

– Flush with warm H2O +/- enzymes – If does not work, then carbonated diet soda

AMT Bridle:

NG/NJ tube securement device

NG/NJ tube Bridle • Secures NG/NJ tubes via umbilical tape anchor to vomer bone

(nasal septum) • Reduces risks of inadequately secured tubes (i.e. displacement and

feeds aspiration, pressure necrosis, skin breakdown from adhesives) • Reduces costs of frequent replacements (i.e. nutrition interruption,

tube replacement procedures and risks therein, xrays for confirmation of placement)

• With increased pressure on tube, tube diameter will narrow and slip through the clamp to release before damaging the vomer bone

Gastrostomy Tubes

Anatomy of a Feeding Tube External portion visible on or outside the skin • Traditional tube projecting out of skin • Skin level device (button)

External bolster • Sliding ring • Flaps on valve (button) Internal portion within stomach

(retention tip) • Balloon • Mushroom/cupped • Pigtail

Ports • Feeding port • +/- Side port for fluids/meds • +/- Balloon inflation port

Long GT or PEG Tube

• Simplified tube, easy to use, less mechanical failures.

• Protrudes from abdomen, requires securement device in active patients.

• Can be pulled into distal GI tract.

Corflo®Max PEG Tube (Balloon tip)

Bard long gastrostomy tube (Obturated tip)

Button GT: Measurements

French size = diameter of tube (stoma) 1 French = 1/3 mm

Length in cm = thickness of abdominal wall

Button GT: obturated

• No balloon, but obturated or mushroom-shaped tip prevents dislodgement.

• Obturated tip is firm and usually painful upon removal – usually requires sedation for planned removal.

• Extension does not lock into place – detaches often with active patients.

Bard* Button Gastrostomy Tube

Button GT: balloon • Balloon keeps button in

place

• Silicone material of the balloon can break

• Low profile – close to surface of skin

• Extensions lock into place

Halyard (Kimberly-Clark) Mic-Key

AMT Balloon Mini ONE

Coviden NutriPort

Gastrojejunostomy (GJ) Tubes

GJ long tube

Mic-Key GJ tube

Mini GJ tube

GJ Tubes • Placed in IR • Usually does not need sedation if converting from GT to GJT • Run continuous feeds in “Jejunal” or “J” port • Vent stomach from or give medications in “Gastric” or “G”

port • Inflate balloon via separate side port (“BAL”) • J portion of tube has radiopaque maker to allow

visualization during placement in IR • J portion of tube can clog – small diameter, tube can kink

Jejunostomy (J) Tubes • Usually placed by surgeon in OR • Direct stoma through skin into loop of jejunum via

enterotomy • Usually a long tube is placed first, then can be changed

to button tube once stoma has epithelialized • Increased risk of bowel obstruction and stricture,

peritonitis in immediate postoperative period • Avoids gastric outlet obstruction with tube through

pylorus (as in GJT)

Enteral Tube Placement GT: • Percutaneous endoscopic: GI for visualization with endoscopy, surgeon for tube placement • Interventional radiology: fluoroscopic imaging • Surgical: Open vs. Laparoscopic

GJT: • Most common: exchange GT for GJT in IR after GT stoma epithelializes (4-6 weeks after initial GT

placement) • Primary GJT placement by surgery (less common)

Direct JT: • Tube primarily placed in loop of jejunum, laparoscopic vs open

GT/GJT/JT Care • Know type & size of tube, balloon volume

• Postoperatively:

– 24 hours prophylactic IV cephalosporin

– Begin early feedings, sometimes starting with Pedialyte vs straight to formula – usually continuous feeds first

– May place G portion of GJ tube to intermittent suction for post-op gastroparesis

– Provide Foley catheter (same F size as tube and one size smaller) to place in new stoma immediately after an accidental pull-out

• Maintenance:

– Clean daily with soap and water, avoid hydrogen peroxide

– Tube should be able to move up and down 1 cm and rotate 180°

– Check balloon volume and change tube monthly (may depend on health plan and # tubes provided to patient per month)

G-Tube Dislodgement

• If within 6 weeks of initial placement: – Foley one size smaller, do not inflate balloon or feed – Fluoroscopy to replace ASAP

• If after 6 weeks: – Can replace at bedside – Foley of similar diameter, secure with tape on skin – Check for gastric secretions then can restart feeds

• If not noticed for several hours: – Place NG, intermittent suction, broad spectrum IV antibiotics – Can replace new GT in approx. 7-10 days

Replacing an established GT • Equipment: Lubricant gel, new

device, NS, 10 ml syringe

• Prep new tube

– Check size and balloon integrity

– Deflate and lubricate

• Remove old tube

– Deflate balloon fully with syringe

– Pull out firmly, usually has some resistance

• Insert new tube into stoma

– Inflate balloon fully, tug to check if secure

– Firmly pull up, push external bolster down with 2-5 mm slack

• Confirm placement

– Aspirate tube for gastric contents

– Consider GT contrast study

Discontinuing a GT

• Most fistulas spontaneously close in 48 -72 hours

• Persistent (gastric drainage > 2 months)

– Prolonged placement (> 8-12 mo), large diameter (14 Fr)

– Malnutrition, obesity, straining cough, debilitating dz

• Non-operative closure: 2-octylcyanoacrylate (2OC)

– Tissue adhesive: stimulates tissue inflammation and fibrosis

– Cost effective, non-invasive, no anesthesia, outpatient setting

• Surgical excision and closure of fistula

Clogged tube

• Prevention – Flush tube with water after feeds and medications – Use liquid form of meds – Consider flush volume in total daily

• Management

– Push and pull 1-3 ml of warm H2O, carbonated soda, pancreatic enzyme, or papain

– No stylet - breaks valves – Last resort is to replace tube

Cecostomy Tubes (C tubes)

Chait Trapdoor

C-tube: Indications & Placement • Chronic refractory constipation and fecal incontinence • Placed by IR or laparoscopically by surgery

– 2 days bowel prep – Perioperative IV antibiotics – Initial tube long, change to low-profile after 2 months

• Risks – Peritonitis – Abscess – Bleeding – Injury to other structures

C-tube: Management

• Daily care – Clean daily with soap and water – Keep tubing secure

• Enema regimen (begin 1-2 weeks after initial placement) – Have patient sit on toilet – Flush enema regimen as prescribed – Have activities for patient (DVD, books, etc), can take up to 1 hour to complete

stooling – Clean site and equipment after completed

• Tube change – Every 6 to 12 months after initial long tube changed to low-profile

C-tube: Complications • Infection

• Leakage

• Granulation tissue

• Dislodgement

– Place foley catheter, do not inflate balloon

– Replace in IR

References • Lukish J. The Care of Lines and Tubes in Children. Contemporary Pediatrics Oct 2010; 59-75. • Burd A, Burd RS. The Who, What, Why, and How-To Guide for Gastrostomy Tube Placement in Infants. Advances in Neonatal Care 2003; 3 (4): 197-

205. • El-Matary W. Percutaneous Endoscopic Gastrostomy in Children. Can J Gastroenterol Dec 2008; 22(12): 993-998. • El-Matary W. Percutaneous Endoscopic Gastrojejunostomy Tube Feeding in Children. Nutrition in Clinical Practice Feb 2011; 26(1): 78-83. • Friedman JN. Enterostomy Tube Feeding: The Ins and Outs. Paediatr Child Health Dec 2004; 9(10): 695-699. • Kutiyanawala MA, et al. Gastrostomy Complications in Infants and Children. Ann R Coll Surg Engl 1998; 80: 240-243. • Nijs ELF, Cahill AM. Pediatric Enteric Feeding Techniques: Insertion, Maintenance, and Management of Problems. Cardiovasc Intervent Radiol 2010;

33: 1101-1110. • McClave SA, Neff RL. Care and Long-Term Maintenance of Percutaneous Endoscopic Gastrostomy Tubes. Journal of Parenteral and Enteral Nutrition

Jan-Feb 2006; 30(1 Suppl): S27-38.

• Goodman DM, et al. Current Procedures Pediatrics. The McGraw-Hill Companies, Inc. 2007; 114-6, 120-2.

• Mahant, S. (July 2010) Technical Trouble-Shooting: The role of the hospitalist in managing technological devices. Enterostomy Access: Gastostomy and Gastrojejunostomy Tubes. Presented at Pediatric Hospital Medicine Conference in Minneapolis, MN

Closing Discussion

Yes, we can…

…but should we?

Goals of Care • Planning ahead • Palliative Care • Overall goals of care • Advanced directives • Medical power of attorney • Decision-making capacity of caregivers • Access to emergency and home care services • Access to hospice services • Care transitions for aging patients and caregivers

Educational Resources • Radiopaedia.org

• http://pediatrics.ucsf.edu/blog

• http://dontforgetthebubbles.com

• http://lifeinthefastlane.com

Thank you!!!

From Wendy, Sam, Kiran, and Sarjita

warafiles@phoenixchildrens.com sflores2@phoenixchildrens.com

sshukla@phoenixchildrens.com kmangat@phoenixchildrens.com